eMedicine Specialties > Plastic Surgery > Facial Fractures

Facial Trauma, Zygomatic Arch Fractures: Workup

Author: Adam J Cohen, MD, Consulting Surgeon, Eyelid and Oculofacial Aesthetic and Reconstructive Surgery, Diseases and Surgery of Orbit and Lacrimal System, Director, Center for Facial Rejuvenation
Contributor Information and Disclosures

Updated: Jan 27, 2009

Workup

Laboratory Studies

  • If alcohol or illicit drug use is suspected, obtain and document serum levels.
  • As with most surgical patients, appropriate preoperative laboratory tests (eg, complete blood cell count, metabolic panels, activated partial thromboplastin time) and an international normalized ratio are necessary. Obtain a pregnancy test when clinically warranted.

Imaging Studies

  • A chest radiograph may be necessary before proceeding with the repair.
  • Roentgenograms can be used but are limited by the lack of ability to detect differences in tissue density of less than 10%, making evaluation of soft tissue difficult at best. Standard facial series are the norm and are obtained with varying angulation of the x-ray beam vector.
    • The Caldwell projection allows for visualization of the orbital floor and zygomatic process above the dense petrous pyramids. A submental vertex view affords excellent detail of the zygomatic arches.
    • Anterior-posterior and Waters views reveal much less about the zygomaticomaxillary complex (ZMC) than other planes and are of limited value.
  • Computed tomography (CT) scans have supplanted radiographs in the evaluation of midfacial trauma and are the current modality of choice.4
    • A gray-scale image is created based on various soft tissue linear coefficients that are assigned a particular shade of gray.
    • Direct axial, coronal, or sagittal images can be obtained with proper positioning of the patient.
    • CT scanning without contrast provides views of high-density bone.
    • Obtain both axial and direct coronal, 1.5- to 2-mm cuts to properly evaluate the orbit. If the patient cannot be manipulated into proper position for direct coronal images, coronal views also may be obtained indirectly by a reformat of thin axial windows. Coronal orbital views provide bone and soft tissue windows, allowing for detailed images of the lateral orbital wall, ZMC, and adjacent soft tissue and bone structures.
  • Magnetic resonance imaging (MRI) uses a magnetic field and the activity of hydrogen atoms within this field to produce magnificently detailed images of the orbit.
    • MRI enables multiplanar imaging and is excellent for evaluating soft tissue masses and optic nerve pathology.5
    • Although MRI provides exquisite detail of the orbital region, CT scanning remains the imaging modality of choice for evaluation of orbital trauma because of its ability to discern detail of bony structures.
    • Of note, intraocular ferromagnetic foreign bodies can add additional insult to the eye and surrounding structures secondary to the magnetic field of MRI.

Other Tests

  • An electrocardiogram also may be necessary before proceeding with the repair.

More on Facial Trauma, Zygomatic Arch Fractures

Overview: Facial Trauma, Zygomatic Arch Fractures
Workup: Facial Trauma, Zygomatic Arch Fractures
Treatment: Facial Trauma, Zygomatic Arch Fractures
Follow-up: Facial Trauma, Zygomatic Arch Fractures
Multimedia: Facial Trauma, Zygomatic Arch Fractures
References
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References

  1. Covington DS, Wainwright DJ, Teichgraeber JF, Parks DH. Changing patterns in the epidemiology and treatment of zygoma fractures: 10-year review. J Trauma. Aug 1994;37(2):243-8. [Medline].

  2. Manson PN, Clark N, Robertson B, et al. Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures. Plast Reconstr Surg. Apr 1999;103(4):1287-306; quiz 1307. [Medline].

  3. Terino EO. Alloplastic contouring in the malar-midface-middle third facial aesthetic unit. In: Terino EO, Flowers RS, eds. The Art of Alloplastic Facial Contouring. St. Louis, Mo: Mosby Year-Book; 2000:79-96.

  4. Kelley P, Hopper R, Gruss J. Evaluation and treatment of zygomatic fractures. Plast Reconstr Surg. Dec 2007;120(7 Suppl 2):5S-15S. [Medline].

  5. Laine FJ, Conway WF, Laskin DM. Radiology of maxillofacial trauma. Curr Probl Diagn Radiol. Jul-Aug 1993;22(4):145-88. [Medline].

  6. Turk JB, Ladrach K, Raveh J. Repair of zygomaticomalar complex fractures. The Swiss method. Arch Facial Plast Surg. Apr-Jun 1999;1(2):123-6. [Medline].

  7. Honig JF, Merten HA. Classification system and treatment of zygomatic arch fractures in the clinical setting. J Craniofac Surg. Nov 2004;15(6):986-9. [Medline].

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  9. Czerwinski M, Lee C. The rationale and technique of endoscopic approach to the zygomatic arch in facial trauma. Facial Plast Surg Clin North Am. Feb 2006;14(1):37-43. [Medline].

  10. Gülicher D, Krimmel M, Reinert S. The role of intraoperative ultrasonography in zygomatic complex fracture repair. Int J Oral Maxillofac Surg. Mar 2006;35(3):224-30. [Medline].

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  13. Matsunaga RS, Simpson W, Toffel PH. Simplified protocol for management of malar fractures. Trans Am Acad Ophthalmol Otolaryngol. Sep-Oct 1977;84(5):ORL818-9. [Medline].

  14. Shaw GY, Khan J. Precise repair of orbital maxillary zygomatic fractures. Arch Otolaryngol Head Neck Surg. Jun 1994;120(6):613-9. [Medline].

  15. Shumrick KA, Campbell AC. Management of the orbital rim and floor in zygoma and midface fractures: criteria for selective exploration. Facial Plast Surg. 1998;14(1):77-81. [Medline].

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  19. Matsunaga RS, Simpson W, Toffel PH. Simplified protocol for treatment of malar fractures. Based on a 1,220- case, eight-year experience. Arch Otolaryngol. Sep 1977;103(9):535-8. [Medline].

  20. Rajesh P, Rai AB. A comparison between radiography and ultrasonography in the diagnosis of zygomatic arch fracture. Indian J Dent Res. Apr-Jun 2003;14(2):75-9. [Medline].

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Further Reading

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Keywords

zygomatic arch fracture, isolated zygoma fracture, isolated zygomatic fracture, face trauma, zygomaticomaxillary complex fracture, ZMC fracture, motor vehicle accident, MVA, motorcycle accident, sports injury, sports-related trauma, facial fracture, traumatic facial injury, tetrapod fracture

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Contributor Information and Disclosures

Author

Adam J Cohen, MD, Consulting Surgeon, Eyelid and Oculofacial Aesthetic and Reconstructive Surgery, Diseases and Surgery of Orbit and Lacrimal System, Director, Center for Facial Rejuvenation
Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology and American College of Surgeons
Disclosure: Nothing to disclose.

Medical Editor

James F Thornton, MD, Assistant Professor, Department of Plastic and Reconstructive Surgery, University of Texas Southwestern
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jaime R Garza, MD, DDS, FACS, Consulting Staff, Private Practice
Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Allergan Honoraria Consulting

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Deepak Narayan, MD, FRCS, Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center
Deepak Narayan, MD, FRCS is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Indian Medical Association, Plastic Surgery Research Council, Royal College of Surgeons of Edinburgh, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

 
 
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